At the time the elderly woman was admitted to the hospital, two operating rooms were occupied with surgeons carrying out a liver transplant and a blood vessel procedure.

Doctors diagnosed the woman with ileus, a blockage of the small or large intestine. But her condition was judged to be “relatively mild” and she was kept under observation.

As her condition progressively worsened, she underwent an operation seven hours after first being admitted to the hospital.

She died of organ failure a day after the operation took place. A so-called Lex Maria complaint was to filed in June 2008 and investigators have recently reported their findings.

Sweden’s National Board of Health and Welfare (Socialstyrelsen) points to “shortfalls in communication and cooperation” at Sahlgrenska as well as “unclear or non-existent” routines.

Investigators also expressed their surprise that one of Sweden’s largest hospitals could only cope with two operations at a time.

The inquiry noted the hospital was under significant pressure when the woman was moved to the intensive care ward. Nineteen patients were being treated, almost doubling the ward’s ten-bed capacity.

According to Sahlgrenska medical chief Mats Tullberg, the hospital has now taken measures to expand its intensive care ward.

”And we have made it clear to all personnel that if a patient needs emergency treatment, a further operating room must be opened,” he told newspaper Göteborgs Posten while assuring that no future patients will be afforded the same fate.